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Double Reporting and Second Opinion in Head and Neck Pathology Eur Arch Otorhinolaryngol DOI 10.1007/s00405-014-2879-8 EDITORIAL Double reporting and second opinion in head and neck pathology Julia A. Woolgar • Asterios Triantafyllou • Lester D. R. Thompson • Jennifer L. Hunt • James S. Lewis Jr. • Michelle D. Williams • Antonio Cardesa • Alessandra Rinaldo • Leon Barnes • Pieter J. Slootweg • Kenneth O. Devaney • Douglas R. Gnepp • William H. Westra • Alfio Ferlito Received: 15 December 2013 / Accepted: 31 December 2013 Ó Springer-Verlag Berlin Heidelberg 2014 Introduction: definitions seen by two pathologists may or may not be mentioned in the report, often determined by individual practice, medi- This editorial aims to discuss the practice of ‘‘double cal-legal environments and relative value units of work- reporting’’ and ‘‘second opinion’’ diagnosis in routine load. The final report may be signed by all pathologists diagnostic pathology interpretation. It does not encompass who reviewed the case or might simply include a statement reviews performed as part of audit and quality assurance that the ‘‘case has been reviewed by {name of reviewer(s)}, functions, but is from the perspective of experienced head who concur(s) with the diagnosis’’. In case of a major and neck and oral and maxillofacial specialists. disagreement between experienced pathologists in the ‘‘Double reporting’’ generally refers to showing a case same unit (e.g., benign vs. malignant), additional evalua- to one or more colleagues working in the same histopa- tion should be solicited and the issued diagnosis may be a thology unit before issuing a malignant diagnosis [1]. majority decision. This difference of opinion should be When there is concurrence, the fact that the case has been mentioned in the report, with typical examples including cases of melanoma or hematopoietic and lymphoid neo- This paper was written by members of the International Head and plasia. The practice of ‘‘double reporting’’ varies between Neck Scientific Group (www.IHNSG.com). J. A. Woolgar Á A. Triantafyllou A. Rinaldo Á A. Ferlito (&) Oral Pathology, School of Dentistry, University of Liverpool, ENT Clinic, Piazzale S. Maria della Misericordia, Liverpool, UK University of Udine, 33100 Udine, Italy e-mail: [email protected] L. D. R. Thompson Department of Pathology, Woodland Hills Medical Center, L. Barnes Woodland Hills, CA, USA Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA J. L. Hunt Department of Pathology, University of Arkansas for Medical P. J. Slootweg Sciences, Little Rock, AR, USA Department of Pathology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands J. S. Lewis Jr. Department of Pathology and Immunology and Otolaryngology- K. O. Devaney Head and Neck Surgery, Washington University School of Department of Pathology, Allegiance Health, Jackson, MI, USA Medicine, St. Louis, MO, USA D. R. Gnepp M. D. Williams Department of Pathology, Warren Alpert School of Medicine at Department of Pathology, The University of Texas MD Brown University, Rhode Island Hospital, Providence, RI, USA Anderson Cancer Center, Houston, TX, USA W. H. Westra A. Cardesa Departments of Pathology and Otolaryngology-Head Department of Anatomic Pathology, Hospital Clinic, and Neck Surgery, The Johns Hopkins Medical Institutions, University of Barcelona, Barcelona, Spain Baltimore, MD, USA 123 Eur Arch Otorhinolaryngol diagnostic histopathology units worldwide, from non- Such costs are certainly measurable for formal second existent to voluntary to mandatory. Nevertheless, increas- referral, but these data are largely unavailable for ‘‘double ing risk from medical litigation may eventually tip the reporting’’. scales towards mandatory double reporting as a standard More subtle and less measurable reasons why ‘‘double protocol for subsets of pathology diagnosis, such as reporting’’ may not be widely practiced could include malignant lesions. ‘‘Double reporting’’ may also be applied interpersonal issues, and perhaps (rarely) a negative atti- to unusual, rare, and difficult diagnoses, including benign tude towards ‘‘having one’s work checked’’, or practical lesions. The variations in practices have made comparisons issues such as turnaround time delays that might occur with between institutions difficult, with very little reported lit- this practice. Voluntary double reporting would appear to erature. Nevertheless, a study involving 45 laboratories in be good practice, and is probably commonplace in most the USA reported a median rate of review of about 1 in 12 diagnostic units. Most pathologists develop a particular cases, with malignancy and difficult diagnosis being the interest and knowledge in specific organs or systems, and primary reported reasons for review [2]. The study docu- in many departments, this sub-specialization is encouraged mented that head and neck lesions accounted for 4.1 % of and the diagnostic workload organized so each pathologist cases with ‘‘double reporting’’, while three-fifths were primarily reports cases within his (her) sphere of interest. focused on gastrointestinal tract, breast, skin and female Even when cases are not assigned to ‘‘specialists’’, genital tract lesions [2]. pathologists tend to seek the advice of colleagues when Referring a case for a ‘‘second opinion’’ implies the faced with a difficult case outside their area of particular traditional, formal approach of sending a case to an interest or knowledge. external, recognized specialist department or individual Double reporting, especially mandatory double report- pathologist with experience and expertise in a particular ing of malignancies, may be criticized as time-consuming field. It often involves rare or difficult cases where the and/or unnecessary when a diagnosis is straightforward. referring pathologists are uncertain of the diagnosis, rec- For example, it is unlikely that a second pair of eyes is ognize the inherent challenges of the case and regard needed for a moderately differentiated squamous cell car- ‘‘second opinion’’ part of their required/expected diligence cinoma (SCC) that invades submucosal skeletal muscle. It in working up and finalizing a diagnosis. Other reasons may, however, be helpful in a case of a very well-differ- include the lack of access to required laboratory investi- entiated squamoproliferative lesion without submucosal gations, tests, or molecular testing to confirm a diagnosis. invasion [3]. Selecting subsets of notoriously difficult or ‘‘Second opinion’’ may be retrospective when there is an challenging cases for double reporting may be a useful institutional review of outside pathology slides as a stan- compromise to help alleviate potential turnaround time dard protocol for referral patients before definitive treat- delays. Further, double reporting may provide additional ment. A retrospective request for ‘‘second opinion’’ can consistency in reporting, as both pathologists agree on the also be made directly by the patient, relatives or legal terminology to use and thereby standardize their diagnostic representatives. This may occur after investigation into the nomenclature. This practice is supported by the United diagnosis by the patient and is becoming more common States military services, where all malignancies are with the universal availability of the internet, lay access to mandatorily prospectively double read to enhance diag- medical literature and litigation. Finally, ‘‘second opinion’’ nostic fidelity and patient management. can be retrospectively requested when departmental audit or quality assurance reveals a disagreement between pathologists that cannot be resolved internally. ‘‘Second opinion’’ can account for a significant component of a Overview of ‘‘second opinion’’ specialist head and neck/oral and maxillofacial patholo- gist’s workload. The number of ‘‘second opinion’’ evalu- Although there are no guidelines for identifying cases that ations should be audited when assessing target workloads should be sent for second opinion, auditing of pathology for individual pathologists. reports uncovers discrepancies across all major organ systems and shows some body sites and some lesions which are more prone to yield errors [4–6]. Site specific Reject, endorse or enforce ‘‘double reporting’’? studies have shown that the head and neck area is a high- risk site, right behind the female reproductive tract and the Although a priori beneficial to the management of gastrointestinal tract [7, 8]. Within head and neck areas, the patients, ‘‘double reporting’’ and ‘‘second opinion’’ may thyroid gland is an error prone site [7], although the be influenced by logistical and other factors, including establishment of this organ as a specific specialty along costs from manpower, time and consumable resources. with increased awareness has resulted in improvements. 123 Eur Arch Otorhinolaryngol Excluding the nature of the referred cases, further clinician is generally considered good practice. Providing exploration of the significance of ‘‘second opinion’’ interim or provisional information to the clinician can help requires awareness of the timing and routes of the requests, them to understand the reasons for the delay in reaching a and the common reasons and difficulties precipitating a final diagnosis, to plan future patient appointments and to consultation. These are further examined below. keep the patient informed. Medical ethics and standard accreditation guidelines dictate that a final diagnosis should be timely [8] and Where to send second opinion cases? hence, an external referral case
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